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Claim by Jackie Jones Copyrig hted March 1, 2021 City of Dubuque Consent Items # 2. City Council Meeting ITEM TITLE: Notice of Claims and Suits SUM MARY: 2G2, LLC. for breach of lease;Asbury Square LLC for property damage; Jackie Jones for property damage; additional claim information from Ronald Koehler for property damage;Aaron Rang for vehicle damage; Jacob Schlosser for property damage; additional claim information from State Farm a/s/o Michael or Jennifer Connolly for property damage. SUGGESTED Suggested Disposition: Receive and File; Referto CityAttorney DISPOSITION: ATTACHMENTS: Description Type Claim by 2G2, LLC Supporting Documentation Claim by Asbury Square LLC Supporting Documentation Claim by Jackie Jones Supporting Documentation Additional Claim Information by Ronald Koehler Supporting Documentation Claim by Aaron Rang Supporting Documentation Claim by Jacob Schlosser Supporting Documentation Additional Claim Information by State Farm a/s/o Supporting Documentation Michael or Jennifer Connolly �� i i� Confidential This communication and any attachments may contain information which is confidential � and privileged by law and is for the use of the designated recipient. If you are not the Iy� intended recipient, you are hereby notified that you have received this communication in '1 error, and tha# any review, disclosure, clissemination, distribution or copying of its contents �'r is prohibited. Please notify City of Dubuque immediately by telephone at (563)-589-4120 of i your receipt of these items and destroy the communication and any attachments immediately. Further discBosure of this information may violate state and federal I� restrictions. � � � �� ,, _ ;l Confidentia! information may include the following: ,!, � � � � � � � � � � kl 1) Social Security Number(s) '� 2) Medical/Health Information �'I 3) Personnel/Disciplinary Information jj 4) Bank Account Information ± 5) Financiallnformation + 6) Credit Card Numbers �� il If any documentation you desire to submit to the City of Dubuque contains any of the items above I; this cover sheet must be attached directly to the confidential information and indicate the type of i information that is included. 'i� �� I, h , hereby certify that the attached documents j� include the following protected information: f �; Social Securit Number s �� Y ( ) Bank Account Information MedicaVHealth Information ' Financial lnformation P�r�cnr�VDisciplirary lnforrrat�cn Cr�dit Card Nu�ber(s) I understand that this information may be distributed within the City organization or to agents of the � City for processing and I hereby authorize the City to act accordingly taking all precautions to protect my information from unnecessary distribution. ,,, s � � �� ' nature Date ' u � � B � � �� .�� kl�.s�-e�.�ar� ; CLAIM AGA[NST THE CITY OF DUSUC�UE, IOWA �. 5�i;�'�I' � This written report constitutes your claim against the City of Dubuque, lowa. You should ; complete this form in full and attach any additional information that supports your claim. `,� , The Claim must be filed with the Cpty Clerk at City Hall, 50 W. 13t" St., Dubuque, IA 52001. It 'i will then be referred by the City Council to the appropriate department for investigation. '�� Once that investigation is completed, a report and recommendation will be submitted to the �� City Council. You will be provided with a copy of that report and recomm�ndation. '; , � , THE FINAL DECISION ON ALL CLAIMS IS MADE BY THE CITY COUNCIL. NO EMPLOYEE OF 3 THE CITY OF DUBUQUE HAS THE AUTHORITY TO MAKE ANY REPRESENTATION TO YOU 'i; AS TO WHETHER YOUR CLAIM WILL OR WILL NOT B PAID. '�I � �� 1. Name of Claimant: � , -- II 1 2. Address: �.. ; � City: � '�,��"�—°-'' State: % ' Zi 'i p: � ; � ,� �' ;— I 3. Telephone Number: �� . �" �; 4. Date of Incident:� / � �1 I 5. Time of Incident: �� 'li 6. Loca ion of Incide (Be s eci ic): � �� ,7 ; � �a � I i ;� 7. DES R � �D OR OC RR NC AT Ca4USED INJURY OR DAM �`� AGE. (Gsve �, full details upon which you base your claim. If a City employee was involved, give the �� employee's name.) li a II�,.�� LT.� � � � � ja . ,...,✓ ._ . . � 8. What were weather conditions like? .S"�fi(�r� 9. Give name and address of any witnesses: � 10. Did police investigate? (If so, give names of officers.) t l��'��./ ,1�=��f f'��. � � 11. Was anyone injured? (If so, give names, addresses, and extent of injuries). � o�� i 12. Was any damage done to property? (If so, describe property and the extent of J damages. Attach estimates of damages or describe basis for ascertaining extent of � damage.) - �`� � �1�7f.�U'� .;�:C��-'�`�,V"` ��V"C��'�,�dC.��..� i'� r��v` 5G�CL /""i� .fr. `� � . n.� n� . I � 13. What other damages do you claim, if any? � 4 � �I ;� 14. Have you been compensated for any part or all of your �laim by any insurance Ii company? (If so, give name and address of insurance company and amount paid.) �, ,� fl � �I 15. 1lVhat amount do you claim from the Gity of Dubuque?�"`�� I''� 16. Why do you claim the City of Dubuque is responsible? �� "��3�''�� ' � E �� 'i '�,i 17. Have you made any claim against anyone else for damages as a result of this incident? ,; (If yes, give name and address.) � �� ++�'�'rr� . � . . d I�i 18. If the answer to Question 17 is yes, have you received any payment frorr� that source, '�; and if so, in what amount? j; �i11 �i � Dated at Dubuque, lowa this � day of �'J,�.. �" , 2n�-��,, � J � �� r .�'ignature) . r._.� "s-."r....�--=- �/ ".�"_""�"`-,- �-� � �.. ' :� � . _ ::� - rint Name) =' � r�`�a' �: :� c-� c�-� �� : � � �`� � �� - f� ;� :�'�;' � i.�J -� � � (Rev. 5/18) �' � � � � � � F�IIt"�r� �t �t�iCr'!� Wt�en Sh�ut�[ I�it��l��rsi� , I If you hav�sus#ained an injury or darnag�fQr wh`rch you betr�ve the City ar one aF ifs em�itc�y�es is respc,nsibie,Y�u ' i may file�ctaim ag�inst th��if}�, . ( i How T,�a 1 Requ�st��laim fi�rm? '1 In arder ta tib#ain a clatm farrsi,�lease cantact ar visit ane of th�faltowirig CiEy nffices: II � Git Glerk's t�ffice Gif I�to e `s Of�ic� �ity Ft�ll Harbc�r View PCace,Ste.33Q IJ �t�iN,93th St. �OC}Main Sf. ii r�u��,�u�, �t��aa� r��,��u�,rA�zao� ,� �s�.��s,�.��a ;�s�.s$�.�� , C�n 1��nr� tr�Additibrta![nForm�tir�r�'vtrith�the Cl��itt �'c�rm� I Ye�.1E,is r�comrn�nd�d that you�en�i in�s much inf�rm�tion�s posslbl�v,r�tFi yaur claie�r for€r�ir�ard��#o expedite th��nv�stigation c�f the ciaim:Thts incCudes,but is n4t I'rrriited�r�,esiirrtates,r�ceipts,med'rcal E�i([s,picture�and any � oth��trtfc�rma�iran you f`�e{may be r�leu�nk tca yr�ur clairn, 1#Is�lsr�tecamm�nct�d ihat yo.0�end.in cn�[�s raP fhese � lfecns and kee��he ctriginals fcir your�ecords,. ii ,, li V�1��H�ppen�A,ft�r 1 �ii�Nty�tainn� il t?n��a�laim h�s b��n t�ceiv�d�nd f�l�-sfampad by fhe Gity Gl�rk;it is i�aru�rardect ic�fiie C�ty Atfarr�ey's Ct��ce fn�° �'�i inu�:sti�at�nn,�iairns irlvolving personai inj�r�y or suL�sE�n[i�[praperty+�amag�will b�farwarded to fhe�lty`s cla�riis ,; �geney far Investt�atic�f�.Yc�u wil(reaeiv�a t�tter f�r�rn the�ity,Aftarriey'�C)f�c�inc#i�atin�that yaur ctairn I��s ta��n s f�rwardec[to ih�claims�gency,Thi:�ietier u�i�!aPso�ontairt th�c��ims�g�ncy's contact finf,�rmafir�n, !i A�iair�ls adjust�r wift i[�e� �cant�act�rc�u re�arding yaur cialrn.At t��#perinf�arr�r questiarts r�g�rding y�ur clatm �! �h�auld be ad�tres�ed tc�t�e ctairc�s��tjuster.A!1 c�ther clairns�t�11 b�ficsrw�r�fed fa t�a�appropeia��:C�ty depar�ment for � inu�:sti��fiQn,A�fer s�ieakPng v,rith ernptay�e��nd con�ultfn�.d�partme�t rec�ards,the tl�pactrn�nt s�z�an��r! i supe€�saisc�r will rr�ak�a recamrrtendatiQ�as tc�wh�th�r#h�cl�im�hou(d I�e appraued e�r d�nt�d. +a _ Basec2 an iha$ir�f��rriati�r�,the�ity�ttc�rn�:y wilt it�en�ake a rece�mrnend��on E€�#he�ity Gounc�l�s tzs wYretFy�r ihe 1 ctairn sh�ulcl be apprcrveci c�r cfeni�d,tf#i�e��ty�ttQrriey r��r�rnrr�encts thaE the cEaim be�tenied,j�vu wiil receiv�,a i copy r�f the depa�tm�n�man��C I supe�rr'isat's reporf a[�rng�t�ith iY��City Afit�r�rey`s repork fe�fh��ify Cc�uncil, 1f ths Cit�Atta�n�y r��mm�nds€h�t#he ctaim b�approved,you�rttl recetve the�i.ty Attorrr�y`s report to fh��ity , Council��w�i(as a r�Ie�s��i�rrrs ta be sign�e!and reiurn�d te�th��ity fi,�torrtey's Q�ce.These ar��n[y �� r�c�rnrrten�iat�ons. #t is irnpurt�rn�tp no#�;ihat ihe final ciecision vrr all ctaims is made by the Gity�auneil, No errtpiaye�of the Gity has#h�autharity to maKe any eepresen#ation to you as to v;rhether yc�ur�[airtt wiil or wil!o�rat � b�paid. iPlh��ity Couricit approves the claim fr�r paym�nt at its City CaunciC me�ting,�check wifl b�rnailed ta you pravicieci fhe City Attarney's C�ffice has received yaur signed te[ease form. , Vi/ha�i��11Ey G��rri is f�€:r�teci b�the Gft�r C�au�ncii'� The Cify Grauncil makes its determination at�ity Gouncil meetings,wh'sch are hetd#he first and third Mc�nday of each martth.We recarnrrEend wrEting a[et[er ta the City Gauncil indicating why your c�aim should not be denied and any additiana(infiarrnatPon tha#you have to suppor�your claim. It is not necessary#o appeal the Gity At#orney's recommendation for deniaC+�f your claim befar�the Cify Cauncil � makes its defermination,hawev�r,yau may da so.Yau are Invited ta aftend the�iky Gc�uncil meeting when your claim will be decided; howev�r,your attendartce is nok mandato�y and you sfi[I have the right to appeai the Cify �ouncil's declsian any fime��ter it has b�en made. If your c�alm or appeal Is denisd,you have the option of filin�a lawsuit in a r,aurt of a�proprtate jurisdiction. Hc�w Long T�c� ( Have f�Wait Before my Cfaim is Resalued? The tength c�f time tt t�kes to investigate and resoive a ciaim d�pends targeCy an the nafure of the ctaim�nd th� �rnrsunt of dam�ges tnvQ(ve�.�om�cl�ims m�y tak�a f�w v�reeks to r�s�tv�,�rrhlt�ather�rnay fake lortge�I�yau wish#a check ran the std#us of your claim�r if you have any qu�;s#ions ar corrc�rns about the process,contact U'the Clky Att�rney'S C}ffiCe at�63,�$3,41'[3, � � Y�u may file a c€aitn at any fime. However,iF y�uC ctaim is d�nieci by the Gity�ounci!and yocr wish t�fil�a la+r�suit, you sl�puld [ae aware that state law may limit ft��tirrr�in+r�hich#o file a(awsuit. Copyrig hted March 1, 2021 City of Dubuque Consent Items # 3. City Council Meeting ITEM TITLE: Disposition of Claims SUMMARY: CityAttorneyadvising thatthe following claims have been referred to Public Entity Risk Services of lowa, the agent forthe lowa Communities Assurance Pool:Asbury Square LLC for property damage;Ashlynn Johnson for property damage; Jackie Jones for property damage; Aaron Rang for vehicle damage; Jacob Schlosser for property damage; State Farm a/s/o Michael or Jennifer Connolly for property damage. SUGGESTED Suggested Disposition: Receive and File; Concur DISPOSITION: ATTACHMENTS: Description Type ICAP Referral Supporting Documentation THE C1TY OF L��.1B E MEMORANDUM Masterpiece on tlie Mississippi JENNYMESSER PARALEGAL To: Mayor Roy D. Buol and Members of the City Council DAre: February 16, 2021 RE: Claim Against the City of Dubuque by Jackie Jones Claimant Date of Claim Date of Loss Nature of Claim Jackie Jones 02/15/2021 02/12/2021 Property Damage This is a claim in which claimant alleges their vehicle was damaged by a City snow plow. This claim has been referred to Public Entity Risk Services of lowa, the agent for the Iowa Communities Assurance Pool. cc: Michael C. Van Milligen, City Manager John Klostermann, Public Works Director Jackie Jones OFFICE OF THE CITY ATTORNEY DUBUQUE, IOWA SUITE 330, HARBOR VIEW PLACE, 3O0 MAIN STREET DUBUQUE, IA 52001-6944 Te�eaHONe (563)589-4381 /Frvc (563)583-1040/En�tni� jemesser@cityofdubuque.org